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Rheumatology Patient Consent Form

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									Rheumatology Patient Consent Form

Return by fax to Rheumatology, FAX: +44(0)207 842 0903

Manuscript Number RHE-

Patient (parent or guardian) consent for the publication of material about the
patient in Rheumatology

Name of patient in article or photograph:

Date:

I, the patient/parent/guardian (delete as appropriate) give my consent for this material to
appear in Rheumatology. I have seen and read the material to be published.

I understand the following:

1) The material will be published without my name attached and every attempt will be made
   to ensure my anonymity. I understand, however, that complete anonymity cannot be
   guaranteed. It is possible that someone, for example, a person who looked after me if I
   was in hospital, or a relative, may identify me.

2) The material may be published in the monthly journal Rheumatology, which has a print
   circulation of around 2700 and goes world-wide. The journal goes mainly to doctors and
   scientists, but is also seen by many non-doctors and non-scientists including journalists.

3) If published the material will also be placed on the Rheumatology website. At the moment
   the website is only available to journal subscribers; however, material in the archive that
   is more than 1 year past its publication date is open to everyone for free.

4) The material may also be used in future local editions of Rheumatology that may be
   published in countries such as India and Spain.

5) The material will not be used for advertising or packaging.

I also give consent for the following material to be used in other publications that may
approach Rheumatology so long as the following criteria are met:

1) The material will not be used for advertising or packaging.

2) The material will not be used out of context – for example, a picture will not be used to
   illustrate an article that is unrelated to the subject of the photograph.



Signed:

Patient/parent/guardian (delete as appropriate)




                                            Rheumatology, Bride House, 18-20 Bride Lane, London EC4Y 8EE, UK

								
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